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SASKATOON HEALTH REGION

SUCTIONING ARTIFICIAL AIRWAYS


in ADULTS

Tracheostomies and Endotracheal Tubes

RN AND LPN LEARNING PACKAGE

RN – SPECIAL NURSING PROCEDURES


ƒ Suctioning Non-Ventilated Adult Patients with an Artificial Airway in Place
ƒ Suctioning Ventilated Adult Patients

&

LPN – ADDED SKILL


ƒ Suctioning a Non-ventilated Adult patient via a Tracheostomy Tube in a
Well-Healed Stoma

Registered Nurses and Licensed Practical Nurses identified by their Manager will
be certified to perform suctioning via endotracheal and/or tracheostomy tubes
in accordance with the policy of the clinical unit.

DATE: June 2005


*Pediatric information removed May 2010

This material was developed for the use of Saskatoon Regional Health Authority
(SRHA). This material may not be suitable for other agencies. SRHA makes no
warranties or representations regarding this information, and each agency is
urged to update and modify this information for its own use.
Suctioning Artificial Airways Learning Package i

Permission for extensive copying of this learning package for scholarly purposes
may be granted. It is understood that due recognition will be given to the
Coordinator(s) of this learning package and to the Department of Nursing Affairs
in any use of this material. Copying, publication or any other use of this learning
package for financial gain without approval is prohibited.

Requests for permission to copy or to make other use of this material in this
learning package, in whole or in part, should be addressed to:

Department of Nursing Affairs


c/o Nursing Affairs Office c/o Nursing Affairs Office c/o Nursing Affairs Office
Royal University Hospital Saskatoon City Hospital St. Paul’s Hospital
Saskatoon, SK Saskatoon, SK Saskatoon, SK
S7N 0W8 S7K 0M7 S7M 0Z9

ACKNOWLEDGEMENTS:

Coordinated by:

Chrystal Grant Clinical Nurse Educator, Rehabilitation Unit


Saskatoon City Hospital

Evelyn Seip Clinical Nurse Educator, Intensive Care Unit


Saskatoon City Hospital

*Pediatric information removed by Bernie McDonald May 2010. Pediatric


information is included in Suctioning Artificial Airways: Pediatric/Neonate
learning package.

Special Thanks to:

Ann Burton Clinical Nurse Specialist


Parkridge Centre

Margot Hawke Clinical Nurse Educator


St. Paul’s Hospital/Royal University Hospital

Helen Sabadash Clinical Nurse Educator


Royal University Hospital/Saskatoon City Hospital

Clinical Nurse Educators Acute Care Sector, Saskatoon Health Region

Site Representatives for Acute Care Sector, Saskatoon Health Region


Respiratory Therapy and Physiotherapy

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Suctioning Artificial Airways Learning Package ii

TABLE OF CONTENTS

1.0 General Information................................................................................. 1

1.1. Criteria for Certification....................................................................... 1

1.2. Criteria for Recertification................................................................... 1

2.0 Theory....................................................................................................... 2

2.1. Assessing the Need for Suctioning .................................................... 2

2.2. Preparing the Patient and Equipment for Suctioning.......................... 3

2.3. Complications of Tracheal Suctioning ................................................ 8

3.0 References ............................................................................................... 11

4.0 Appendix

A. Policies ................................................................................................. 12

B. Respiratory System – Anatomy & Physiology ...................................... 15

C. Artificial Airways ................................................................................... 19

5.0 Review Questions.................................................................................... 23

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Suctioning Artificial Airways Learning Package 1

1.0 GENERAL INFORMATION

1.1. Criteria for Certification

ƒ Review of the learning package and completion of the review questions.

ƒ Satisfactory demonstration of the clinical skills to a Clinical Nurse


Educator in a patient and/or lab setting.

1.2. Criteria for Recertification

ƒ Recertification is required annually for LPNs who are not performing the
skill regularly.

ƒ Recertification is recommended for RNs annually if the skill is not used


regularly.

ƒ Recertification may be done upon the request of the Manager of Nursing,


Clinical Nurse Educator or the individual RN or LPN.

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Suctioning Artificial Airways Learning Package 2

2.0 THEORY

2.1. Assessing the Need for Suctioning

A patient with a tracheostomy or endotracheal tube is less able to increase


intrathoracic pressure for an effective cough to clear secretions. This is
because the artificial airway holds the vocal cords open which normally close
just prior to a cough. Initially, a tracheostomy tube may cause increased
secretions due to irritation.

Since tracheal suctioning may cause complications, suctioning should be done


only when there is exudate present in the upper airways, which the patient is
unable to clear by coughing. Routine suctioning should be avoided as this will
increase chance of mucosal trauma and risk of infection. Remember that
crackles and wheezes are rarely cleared with suctioning because they indicate
obstruction or fluid in the lower airways, which are inaccessible to suctioning.
Chest physiotherapy and positioning may move fluid from the lower airways,
making it more accessible to suctioning.

Humidification of inspired air and systemic hydration assist to:


ƒ Keep secretions thin, easier to move/remove
ƒ Reduce need for suctioning if patient can raise own secretions
ƒ Prevent tube occlusion from thick/dried secretions
ƒ Counteract insensible fluid losses
ƒ Compensate for bypass of upper airway
ƒ Maintain moist mucous membranes to maximize mucocilliary transport in
the lower airways
ƒ Complications of decreased humification are: atelectasis, tracheitis,
pulmonary infection, obstruction, death
ƒ Complications of over humidification are: excessive moisture into
dependent bronchi, tracheal burns if humidity temperature is excessive,
infection

The need for suctioning varies from patient to patient, and with patient
condition. For example: a patient with pneumonia and copious secretions
may need to be suctioned every 10 minutes to maintain airway patency and
allow for ventilation. On the other hand, a patient without lung disease, who
has been intubated only for ventilation, i.e. neuromuscular disease, may need
to be suctioned only once a shift.

2.1.1. Signs and Symptoms Indicating a Need for Suctioning

ƒ Dyspnea, tachypnea, apnea


ƒ Change in respiratory pattern
ƒ Increased respiratory rate
ƒ Change in heart rate and rhythm

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Suctioning Artificial Airways Learning Package 3

ƒ Restless and agitation


ƒ Noisy respirations/abnormal breath sounds: gurgling, wheezing,
crackles
ƒ Decreased Sp02 or deterioration of blood gases
ƒ Deterioration in patient’s color, cool skin
ƒ Use of accessory muscles, nostril flaring
ƒ Ineffective coughing

Patients with the following conditions are more likely to react adversely
to suctioning. Suction these patients with caution.
ƒ Increased intracranial pressure
ƒ Hemodynamic instability
ƒ Recent surgery to the chest and pulmonary structures
ƒ Pulmonary hemorrhage
ƒ Extreme reactive bradycardia (i.e. when the heart rate drops
dramatically in response to suctioning)
ƒ Hyperactive airways

Contraindications to suctioning:
ƒ Epiglottis and/or croup are absolute contraindication for nasotracheal
suctioning since suctioning can worsen these conditions
ƒ Nasal bleeding
ƒ Occluded nasal passages
ƒ Coagulaopathy or bleeding disorder
ƒ Laryngospasm
ƒ Irritable airway
ƒ Upper respiratory tract infection

2.2. Preparing the Patient and Equipment for Suctioning

2.2.1. Preparing the Patient

Suctioning is an uncomfortable and often frightening procedure:


ƒ The patient is intubated and is therefore unable to vocalize
ƒ The presence of the catheter in the trachea may make the patient
highly anxious and restless
ƒ Suctioning may cause hypoxemia
ƒ The patient may have a smothered feeling
ƒ Patients have rated the pain of suctioning at 7 on a pain scale of 1-
10 (Puntillo, 2001)
An explanation regarding the purpose of tracheal suctioning should be
given to the patient and/or family prior to suctioning and throughout the
procedure each time the procedure is done.
Important points to tell the patient and family include:
ƒ Why the patient requires specific aspects of care (i.e. intubation,
suctioning, oxygen before the procedure, instillation of saline)

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Suctioning Artificial Airways Learning Package 4

ƒ Comfort measures taken


ƒ Any other aspects of care regarding the individual needs of the
patient

The patient may benefit from frequent reassurance and instruction on


how to assist the nurse during the procedure. Often during the
procedure, the patient instinctively wants to pull at the catheter,
especially when the cough reflex is stimulated. Warn the patient that
the procedure will make him/her cough. Restraints may be necessary,
especially in the cognitively impaired patients, and with children.

To allay patient fears, suctioning must be performed with confidence


and speed.

Positioning the Patient

Position the patient with head of bed elevated or in appropriate position


for postural drainage unless medically contraindicated (i.e. unstable
spinal fractures).
Rationale: This promotes deep breathing and effective coughing by
allowing maximum movement of the diaphragm.

Oxygenation

If required, extra oxygen may be given before and after each episode of
suctioning. This is most often done with ventilated patients. In the non-
ventilated patient, extra oxygen can be provided using a manual
resuscitation bag attached to oxygen or increase oxygen flow, if
needed. If extra oxygen is not needed, encourage the patient to take
several deep breaths before and after suctioning.

Hyperoxygenation

Hyperoxygenation refers to the administration of oxygen at a greater


concentration than the patient is receiving or usually requires. It is
performed before, during, and after suctioning, based on assessment of
the patient’s respiratory status. Hyperoxygenation can be performed by
an assistant giving 5 – 6 ventilations using a resuscitation bag with
supplemental 02, or by the patient taking several large breaths while
receiving a higher than normal concentration of oxygen, or in the
ventilated patient by increasing the ventilator Fi02. Note: to
hyperoxygenate by ventilator requires 1 – 2 minutes before dead space
in the ventilator is cleared.
Rationale: It is well documented that a decrease in arterial oxygenation
occurs during the tracheal suctioning procedure. The decreased arterial
oxygen tension following tracheal suctioning has been found to lead to

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Suctioning Artificial Airways Learning Package 5

cardiac dysrhythmias, hypotension, and death. Tachycardia may occur


as a reflex response to compensate for the suction-induced hypoxemia.
Hyperoxygenation minimizes suction-induced hypoxemia by maintaining
the Pa02 levels throughout the suctioning period. Manual ventilation
(like mechanical ventilation) also minimizes hypoxemia due to
suctioning-induced atelectasis, by re-expanding sections of the lungs
that may have been evacuated or air and collapsed.

2.2.2. Preparing the Equipment

Suction Catheter

The catheter size will vary depending on the size of the airway:
Adults #12 – 14 Fr. catheters

CORRESPONDING SIZES
CUFFED/UNCUFFED METAL LAERDAL SUCTION
SHILEY ADAPTOR CATHETER
00 5
0 8
1 8
2 10
3 10
4 4 5 10
4 5 6 10
4 6 7 12
4 7 8 12
6 8 9 12
8 14
10 14

The catheter size should be no more than ½ the diameter of the airway.
If the airway is fully occluded with the catheter it may cause a drop in
Pa02. In addition, large catheters and small interior diameter of artificial
airways, when coupled with higher suction flow rates, produce the
greatest negative airway pressures and alveolar collapse. Catheter size
can contribute to suction-induced atelectasis, hypoxia, intrapulmonary
shunting and decreased lung compliance. Catheters with multiple
openings versus a single opening produce less tissue trauma. (Egan,
1995) The catheter may also stimulate the vagus nerve, resulting in
bradycardia and hypotension. Paroxysmal coughing due to catheter
irritation increases intrathoracic pressure, decreases venous return and
produces transient hypotension and syncope. It also increases
intracranial pressure and reduces cerebral blood flow. Cardiac
arrhythmias may occur due to decrease in myocardial oxygen supply or

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Suctioning Artificial Airways Learning Package 6

increase in oxygen demands in the presence of accompanying


tachycardia and elevated blood pressure.

Suction Catheter – Closed System

In ventilated patients, a closed-circuit catheter system eliminates the


need to disconnect the patient from the ventilator during suctioning.
The severity of arterial oxygen desaturation can be reduced by using a
closed system, and unstable patients appear to better tolerate
suctioning when not removed from ventilatory (Maggione, pg 1218,
2003). Refer to Policy and Procedure: Suctioning Adult Patients With
Artificial Airways in Place #1019 for further information.

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Suctioning Artificial Airways Learning Package 7

Suction Trap

ƒ Used to collect sterile sputum specimens when the patient is unable


to expectorate sputum or has an artificial airway in place.
ƒ The sputum trap is placed between the suction catheter and the
suction tubing.
ƒ Please see SHR Infection Prevention and Control Manual and
Laboratory Service Manual for further information regarding use of
sputum traps.

Setting the Suction Pressure

Set suction pressure at:


ƒ 100 – 120 mmHg for adults

Adjust the suction pressure according to the nature of the secretions


being removed. Use the lowest suction pressure that will be effective.
Thick secretions or mucous plugs may necessitate higher pressures. A
physician’s order is required to increase the pressure above the limits
identified above.
Rationale: Damage to the epithelial and mucosal layers of the airways
caused by the presence of an artificial airway is magnified with the
introduction of a suction catheter. Excessive vacuum causes edema,
hemorrhage, and ulceration of tracheal tissue. It can pull air from distal
airways and contributes to atelectasis and decreased lung compliance.
It has not been found to increase the amount of secretions retrieved.

Instillation of Sterile Normal Saline

The instillation of sterile NS should not be done on a routine basis.


(Ridling, 2003) Instillation can contaminate the lower airways and has
an adverse effect on oxygen saturation and arterial blood gases.
Adequate systemic hydration and airway humidification may accomplish
more than instillation (see page 2). Normal saline and secretions don’t

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Suctioning Artificial Airways Learning Package 8

blend when mixed together and therefore the secretions aren’t thinned
for easier suctioning. (Day et al, 2001).

Assess the need for instillation. If required, instill sterile Normal Saline
into the tube, during inspiration:
ƒ 3 – 5 ml (adult)

Side effects of instillation are:


ƒ Decreased PaO2
ƒ Failure to remove all saline
ƒ Increased intracranial pressure
ƒ Risk of Infection
ƒ Hypertension

2.3. Complications of Tracheal Suctioning

Symptoms Prevention
ƒ Hypoxemia/Hypoxia ƒ Decreased oxygen ƒ Limit suction pressure to:
saturation (Sa02 < 90% 100 – 120 mmHg for adults
or below patient’s 80 – 100 mmHg for children
baseline) 50 – 80 mmHg for neonates
ƒ Cyanosis ƒ Limit duration of suctioning
ƒ Cardiac Dysrrhythmias: to:
tachycardia or 10 – 15 sec. for adults
bradycardia ƒ Avoid catheters larger than ½
ƒ Premature ventricular the diameter of the airway
contractions ƒ Manually ventilate as ordered
ƒ Cardiorespiratory until pre-suction status
arrest resumes
ƒ Hyperoxygenate &/or
hyperventilate prior to
suctioning
ƒ Avoid routine suctioning –
suction only as needed.
ƒ Limit number of catheter
passes
ƒ Cardiac Dysrrhythmias ƒ Tachycardia – ƒ Assess for hypoxemia
ƒ Cardiac Arrest/Death decreased arterial ƒ Stop suctioning
oxygen content ƒ Administer oxygen
ƒ Bradycardia – vagal ƒ Manual ventilation as needed
response
ƒ Trauma ƒ Aspiration of blood ƒ Use lowest level of suction
ƒ Tracheal mucosal tinged mucous pressure that will be effective
damage ƒ Decreased air entry ƒ Perform suction procedure
ƒ Pulmonary gently
Hemorrhage/Bleeding ƒ Avoid forcing the catheter

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Symptoms Prevention
against resistance
ƒ Do not apply suction while
inserting the catheter
ƒ Withdraw catheter slightly (1
cm) before applying suction
ƒ Lubricate suction catheter
with sterile Normal Saline
ƒ Limit number of catheter
passes
ƒ Avoid routine suction –
suction only as needed
ƒ Infection: patient, ƒ Increased abnormal ƒ Use sterile equipment;
caregiver secretions in the solutions
trachea ƒ Maintain strict aseptic
ƒ Colonization with gram- technique
negative organisms ƒ Keep ends of oxygen source
ƒ Increased heart rate, clean to reduces possibility of
respiratory rate, and contamination of the oxygen
temperature source
ƒ Use gentle suctioning
technique to avoid trauma
ƒ Optimal hydration, nutritional
and metabolic status
ƒ Avoid routine suctioning –
suction only as needed
ƒ Wash hands before and after
procedure
ƒ For staff protection: use of
gloves, masks, goggles is
recommended
ƒ Hypotension/hypertension ƒ Significant change from ƒ Stop suctioning
baseline BP ƒ Oxygenate and ventilate
ƒ Calm manner while
suctioning
ƒ Pain control
ƒ Atelectasis ƒ Decreased air entry ƒ Limiting amount of negative
ƒ Change in chest x-ray pressure used (see hypoxia
section)
ƒ Keep duration of suctioning
as short as possible (see
hypoxia section)
ƒ Provide hyperventilation
before and after suctioning
ƒ Appropriate size of suction
catheter

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Symptoms Prevention
ƒ Vagal Stimulation ƒ Cardiac dysrhythmias; ƒ Maximize oxygenation
most often before, during and after
bradycardias suctioning procedure
ƒ Calmly reassure patient
during procedure
ƒ Bronchoconstriction/ ƒ Change in air entry ƒ Administer bronchodilators
Bronchospasm ƒ Wheezes auscultated as ordered. May need to do
ƒ Paroxysmal Coughing ƒ Same as for prior to suctioning or give
hypoxemia routinely
ƒ Ventilate patient in “sync”
with patient’s respiratory
effort
ƒ Talk calmly and slowly to
patient to calm them
ƒ May need to
sedate/chemically paralyze
patient if unable to ventilate
ƒ Obstruction ƒ Unable to ventilate ƒ Call for help (Physician,
patient Respiratory Therapist, other
ƒ Unable to suction staff) stat and prepare to
patient change artificial airway
ƒ Continue to attempt to
ventilate patient until help
arrives
ƒ Increased Intracranial ƒ May correspond with ƒ May need to give aerosolized
Pressure increased BP & lidocaine (physician’s order)
coughing 15 minutes before suctioning

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3.0 REFERENCES

Akgul, S. 7 Akyolcu, N. (2002). Effects of normal saline on endotracheal


suctioning. Journal of Clinical Nursing, 11:826-830.

Boutras, A.R. (1970). Arterial blood oxygenation during and after endotracheal
suctioning in the apneic patient. Anesthesiology 32:114.

Buglass, E. (1999). Tracheostomy Care: tracheal suctioning and humidification.


British Journal of Nursing, 8:8, 500-504.

Chulay, M. (1988). Arterial blood gas changes with a hyperinflation and


hyperoxygenation suctioning intervention in critically ill patients. Heart and lung,
17:6.

Day, T., Wainwright, S.P. & Wilson-Barnett, J. (2001). An evaluation of a teaching


intervention to improve the practice of endotracheal suctioning in intensive care
units. Journal of Clinical Nursing, 10, 682-696.

Maggiore, S.M., Et Al. (2003), Prevention of Endotracheal Suctioning-Induced


Alveolar Decrecruitment in Acute Lung Injury. American Journal of Respiratory
Critical Care Medicine, Vol. 167, pg. 1215-1224.

Puntillo, K.A., et al., (2001). Patients’ perceptions and responses to procedural


pain: result from Thunder Project II. American Journal of Critical Care. Volume 10
(4), pp. 238 – 251.

Scanlan, C.L., Ed. (1995). Egan’s Fundamental of Respiratory Care, 6th Edition,
540 – 574.

Royal University Hospital – Nursing Development (1994). Tracheal Suctioning


Self-Directed Learning Package. Author: Saskatoon, Saskatchewan.

Sole, M.L. et al (2003). A multisite survey of suctioning techniques and airway


management practices. American Journal of Critical Care, 12:3, 220 – 232.

For additional references, see policies in Appendix A.

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4.0 APPENDIX A – POLICIES

POLICIES & PROCEDURES

Title: SUCTIONING ADULT PATIENTS


WITH ARTIFICIAL AIRWAYS

I.D. Number: 1019

Authorization Source: Nursing


Cross Index:
[x ]Critical Care Committee Date Revised:
[x] Tri-Hospital Nursing Practice Committee Date Effective: June 2005
Scope: SASKATOON CITY HOSPITAL
ROYAL UNIVERSITY HOSPITAL
ST. PAUL’S HOSPITAL

1. POLICY

Types of artificial airways • Endotracheal tube


• Tracheostomy tube
Personnel who may suction artificial • Certified Registered Nurse and Licensed Practical
airways Nurses – for more information refer to Learning
Package ‘Suctioning Artificial Airways’
• Registered Respiratory Therapist, Physiotherapist,
• Students with supervision (RN, PT, EMT, RT).
Special considerations • Suctioning is a sterile procedure
• The use of protective equipment for staff perfoming
suctioning is mandatory
• Hyperoxygenate patients that require supplemental
oxygen
• Ways to hyperoxygenate include: use of manual
resuscitation device connected to oxygen flow meter
at flush; increasing the oxygen flow of oxygen device
in use; or having the patient take 2-3 deep breaths.
• Hyperoxygenation should be delivered prior to,
during, and post suctioning
• Sterile Normal Saline instillation is not routinely
done
• Use suction catheter that is no more than ½ the
diameter of artificial airway (see chart below for
appropriate sizes)
• Suction should be continuous while withdrawing
suction catheter

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Suctioning Artificial Airways Learning Package 13

CORRESPONDING SIZES

CUFFED/UNCUFFED METAL LAERDAL SUCTION


SHILEY ADAPTOR CATHETER
00 5
0 8
1 8
2 10
3 10
4 4 5 10
4 5 6 10
4 6 7 12
4 7 8 12
6 8 9 12
8 14
10 14

2.0 PURPOSE

2.1To maintain airway patency by removing secretions or foreign objects from trachea.

2.2 To assist the patient in removing airway secretions when the patient is unable to
expectorate on his/her own.

2.3 To stimulate coughing to mobilize secretions.

2.4 To decrease the potential for infection that may result from accumulated secretions.

2.5 To obtain a sputum specimen for diagnostic purposes.

3.0 PROCEDURE

3.1 Endotracheal or Tracheostomy Tube Suctioning – Non Ventilated Patients See


Nursing Interventions and Clinical Skills Textbook, 3rd Ed., pp. 760 – 762, 764, 768
3.1.1 Note the following exceptions to the textbook information
ƒ Suction kits are not routinely used at RUH, SCH
ƒ Suction is pre set on portable suction units
ƒ Do not use sigh mechanism on mechanical ventilator
ƒ Sterile Normal Saline may be drawn directly from the 250ml bottle
ƒ Suction should be continuous while withdrawing suction catheter

3.2 Endotracheal or Tracheostomy Tube Suctioning – Ventilated Patients See Nursing


Interventions and Clinical Skills Textbook, 3rd Ed., pp. 766-768

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3.3 Documentation

• Charting on the Progress Record, Flow Sheet, or Ventilator Record, as per unit
policy, should be done following the procedure. Include the following specifics:
• Amount, consistency, colour, and odor of secretions
• If applicable:
• Hyperoxygenation/Hyperventilation
• Instillation of Sterile Normal Saline
• Chest Physiotherapy
• Specimen sent
• Patient’s tolerance of procedure
• Effectiveness of procedure (ie: lung auscultation)
• Patient/family education provided

REFERENCES:

1. Ackermann, M. H. & Mick, D.J., (1998). Instillation of Normal Saline Before Suctioning
In Patients With Pulmonary Infections: A Prospective Randomized Controlled Trial.
American Journal of Critical Care, 7:4, pg. 261-266.

2. Ackerman, M. H., (1993). The Effect of Saline Lavage Prior to Suctioning. American
Journal of Critical Care, 2: 4, pg. 326-330.

3. Akgül, S. & Akyolcu, N. (2002). Effects of normal saline on endotracheal suctioning.


Journal of Clinical Nursing, 11: pg. 826-830.

4. Elkin, M, Perry, A & Potter, P. (2004) Nursing Interventions & Clinical Skills. 3rd Edtion.
Philadelphia, PA: Mosby. Pg. 760 – 768.

5. Hagler, D. A., & Traver, G. A., (1994). Endotracheal Saline and Suction Catheters:
Sources of Lower Airway Contamination. American Journal of Critical Care, 3: 6, pg.
444-447.

6. Raymond, S. J., (1995) Normal Saline Instillation Before Suctioning: Helpful Or


Harmful? A Review of The Literature. American Journal of Critical Care, 4: 4, pg. 267-
271.

7. Van Hooser, D. T., (2002). Airway Clearance with Closed-System Suctioning. American
Association of Critical Care Nurses.

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APPENDIX B – Respiratory System – Anatomy and Physiology

The respiratory system allows the exchange of carbon dioxide, produced by cellular
metabolism, and life sustaining oxygen. Interference with the functioning of this
system may rapidly result in death.

Respiratory function is regulated by a center located in the brainstem, which


detects blood gas concentrations of oxygen and carbon dioxide, and adjusts the
respiratory rate and depth to maintain homeostasis.

The respiratory system consists of a network of airways that provide the pathway
for the transport and exchange of oxygen and carbon dioxide. The respiratory
system is divided into the upper and lower airways.

Upper Airway
ƒ Consists of the nose, pharynx, larynx and epiglottis
ƒ Major functions of the upper airway are:
ƒ Conducting air to the lower airway
ƒ Protecting the lower airway from foreign matter
ƒ Warming, filtering and humidifying inspired air

During inspiration, air enters through the nose where the nasal cilia filter out
impurities such as small foreign particles (dust, bacteria, some viruses).

From the nose, the air passes into the pharynx. The pharynx is subdivided into the
nasopharynx, the oropharynx and the laryngopharynx. These serve as “hallways”
for the respiratory and digestive tracts. They also play an important role in
phonation.

The larynx is the upper portion of the trachea and connects the upper and lower
airways. It is composed of rings of cartilage, connected by membranes and
muscle. One cartilage forms a complete ring and is called the cricoid cartilage,
located just below the thyroid cartilage. The vocal cords lie inside the thyroid
cartilage. The epiglottis, a flexible cartilage attached to the thyroid cartilage,
functions to prevent the entry of foreign material into the airway when a person
swallows. The function of the larynx is voice production.

Lower Airway

Also called the tracheobronchial tree, the lower airway consists of the tracheal, right
and left mainstream bronchi, segmental bronchi, subsegmental bronchi, and
terminal bronchioles. The major functions of the lower airway are:
ƒ Conduction of air through the many branches of the airways to the alveolar
level
ƒ Provision of the functional mechanism for gas exchange

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The trachea extends from the larynx to the mainstem bronchi and serves as a
passage to and from the lungs. Smooth muscle and C-shaped rings of cartilage
protect the trachea and prevent its collapse.
At its lower end, the trachea divides into the right and left mainstem bronchi. This
bifurcation point is called the carina. One mainstem bronchus enters each lung.
The right bronchus is shorter and wider and extends downward more vertically than
the left. Therefore, aspiration occurs more frequently into the right mainstem
bronchus. The bronchi are composed of cartilaginous rings and ciliated mucous
lining which cleanses the tract by carrying foreign material upward in a blanket of
mucous for expectoration or swallowing.

The mainstem bronchi subdivide in an inverted tree-like formation, branching


through each lung field. The bronchioles are the smallest subdivisions of bronchi.
The bronchioles subdivide further, eventually terminating in microsopic alveolar
ducts and alveolar sacs called alveoli. The walls of these alveoli consist of a single
layer of tissue and are the structures that allow the exchange of oxygen and carbon
dioxide.

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Suctioning Artificial Airways Learning Package 17

Lungs and Accessory Structures

The lungs are located within the thoracic cavity on either side of the heart and
extend from the diaphragm to just above the clavicles. The lungs inflate with
inspiration and deflate with expiration.

The mainstem bronchus, pulmonary blood vessels and nerves enter the lungs at
the hilum, the depression in the medial surface of the lung. The lungs are fully
moveable within the thoracic cavity, except at the hilum (the route of the lungs at
the level of the 4th & 5th vertebrae) where they are anchored by connective tissue
and pulmonary ligaments.

Each lung is divided into lobes. The right lung has three lobes and the left lung
has two lobes. The lobes of the lung are divided into segments. Blood is supplied
by the pulmonary and bronchial arteries.

The lungs are totally enclosed on their outer surfaces by the pleura, a two-layered
membrane. The layer lining the chest wall is called the parietal pleura; that
covering the surface of the lung is the visceral pleura. The two layers of pleura
are continuous with one another and form a closed sac. Normally, there is no
space between them, but rather a potential space called the pleural space. A thin
film of serous fluid lubricates the pleural surfaces to slide smoothly against each
other, and creates a cohesive force that causes the lungs to move synchronously
with the chest during respiration.

The thoracic cavity is the area within the chest wall bounded below by the
diaphragm, above by the scalene muscles, and circumferentially by the ribs,
intercostal muscles, vertebra, and sternum. The thoracic cavity has four
subdivisions:
ƒ The right pulmonary space, which contains the right lung
ƒ The left pulmonary space, containing the left lung
ƒ The pericardial space, which contains the heart and pericardial sac
ƒ The mediastinal space, located at the center of the thoracic cavity between
the two pulmonary spaces, and containing the esophagus, trachea, heart,
and great blood vessels

The diaphragm is the major muscle of ventilation. Relaxed, it forms a dome


shape beneath the lungs. When contracted, it pulls downward, expanding the
thoracic cavity and creating an increased negative pressure, which pulls air into
the lungs. When it relaxes back into its dome shape, air is forced out of the lungs.

The thorax also plays a role in ventilation. The elliptical shape formed by the ribs
and the angle of their attachment to the spine causes the thorax to expand when
the chest is raised (diaphragm contracting) and become smaller when it is lowered
(diaphragm relaxing).

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Suctioning Artificial Airways Learning Package 18

Mechanism of Ventilation
Ventilation is the movement of air in and out of the lungs. It occurs in two phases.
The movement of air into the lungs, termed inspiration, is an active process
involving contraction of the diaphragm and intracostal muscles of the thorax.
Expiration, the movement of air out of the lungs, is normally a passive process,
occurring as the diaphragm and intercostal muscles relax. The stimulus to breathe
is transmitted to the medulla in the brainstem in response to rising blood C02
concentration or falling oxygen concentration. The message is then directed down
through the vagus nerve to the other central and peripheral mechanisms. As the
message to inhale is recognized by the receptors in the chest, the chest cavity
enlarges. This occurs by the diaphragm constraint and flattening and the
intracostal muscle contracting up and outward. The diaphragm is innervated by the
fourth cervical spinal nerve. Individuals with spinal cord injuries at the level of C4
and higher will be ventilator dependent. Individuals with complete injuries at the
level of T6 require assisted coughing techniques due to lack of diaphragmatic
innervation.
Increasing the capacity of the thorax provides space for lung expansion. Pressure
changes in the intrapleural space and within the lung combine to pull the lungs
open, producing a pressure gradient, which causes air to flow into the lungs from
the atmosphere. Inspiration continues until the pressure gradient between the
atmospheric air and the air in the lungs is equal. Air flow then ceases and
expiration commences as the diaphragm and intracostal muscles relax. The
amount of ventilation that occurs is affected and regulated by:
ƒ Respiratory centers in the brain and periphery
ƒ Chemicals in the cerebrospinal fluid
ƒ PaO2, PaCO2
ƒ pH
ƒ Other factors such as pain, temperature, emotions, and physical activity
Exchange of Gases
The exchange of gases between the air and the blood in the terminal alveolar
capillary system is part of the process of respiration. Respiration refers to the
exchange of O2 and CO2 in the body within the lungs, between the cells and their
environment, and in intracellular metabolism.
Normal respiration requires:
ƒ Adequate O2 concentrations in the alveoli
ƒ Adequate amount of haemoglobin capable of binding with O2
ƒ Diffusion of O2 from the alveoli in concentrations sufficient to saturate the blood
adequately before it leaves the lungs
ƒ Transportation of oxygen to the body cells
ƒ Ability of the body cells to use the O2 supplied to them
Gas exchange occurs in the pulmonary alveoli and in the tissues. Pulmonary gas
exchange is affected by ventilation, perfusion, and diffusion. Gas exchange is also
affected by the availability of an adequate concentration of O2 in the inspired air.

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Suctioning Artificial Airways Learning Package 19

APPENDIX C – ARTIFICIAL AIRWAYS:

Overview of Artificial Airways

A Position of Endotracheal Tube B Position of Tracheostomy Tube


Source: adapted from Phipps et al (1995) Medical Surgical Nursing 5th Edition, p. 1021. Mosby-Year Book, Inc.: St.
Louise, Missouri.

Artificial airways bypass normal mechanisms to prevent infection. Patients with


artificial airways are frequently immunocomprimosed and susceptible to infection.
Since the air is no longer moistened, cilia action is depressed leading to thickened
secretions that are difficult to clear. Strength of cough is depressed due to lack of
ability to generate increased intrathoracic pressure against a closed glottis. A
tacheostomy alters motor and sensory functions responsible for coordinating
swallowing, causing increased risk of aspiration.

Endotracheal Tubes

Is an airway tube inserted into the trachea to ensure patency of the upper airway. It
can be inserted through the mouth using an orotracheal tube, or through the nose
using a nasotracheal tube. Adult tubes are almost always “cuffed” to prevent
leakage, allowing their use with a mechanical ventilator, and decreasing chance of
aspiration of orophayngeal fluid. The cuff is a balloon-like device that circles the
lower end of the tube. It is attached to a very narrow tube which connects to the
pilot balloon. This device allows for cuff inflations and quick determination of the
cuff pressure. Once the cuff is inflated there is not airflow through the trachea other
than that going through the endotracheal tube. The size and depth of tube insertion
depends on the size of the patient.

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Suctioning Artificial Airways Learning Package 20

Tracheostomy Tubes

Tracheostomy is an incision made into the trachea. A Tracheostomy is the opening


or stoma created by a tracheostomy incision. (Tamburi). It is either done open or
percutaneously.

The indications for a tracheostomy are:


ƒ Maintain an open functional airway
ƒ Bypass an airway obstruction: tumors, foreign body, larynx or tracheal injury,
soft tissue swelling, oral or nasal intubation is not feasible
ƒ Provide protection from aspiration in patients having difficulty clearing their
airway due to head injury, CVA, progressive neurological disorders (myasthenia
gravis, amolotropic lateral sclerosis)
ƒ Provide mechanical ventilation
ƒ Remove secretions from tracheobronchial tree
ƒ Patients with severe pulmonary disease or pulmonary depression with hypoxia
or hypercapnia need supplemental oxygen
ƒ Following prolonged intubation
ƒ Obstructive sleep apnea

Types of Tracheostomy Tubes

Universal
ƒ Also called the double-lumen or double-cannula tube
ƒ This is the most common type of tracheostomy tube
ƒ It has three parts:
ƒ Outer cannula – can be either cuffless or with cuff and pilot tube
ƒ Keeps the airway open
ƒ Cuffed Tube – when inflated, this tube seals the airway and prevents
the aspiration of oral or gastric secretions. The cuff directs air through
but not around the tube. It is commonly used when mechanical
ventilation is required.
ƒ Cuffless Tube – Usually double-lumen tubes, cuffless tubes are used
for the long-term management of patients. The patients must have
effective cough and gag reflexes to protect themselves from aspiration.
Cuffless tubes are rarely used in acute care.
ƒ Inner cannula – Fits inside the outer cannula and is removed regularly for
cleaning if nondisposable. If the inner cannula is disposable, a new one is
inserted each time the old one is removed. It has a universal adapter for use
with a ventilator and other respiratory equipment.
ƒ Obturator – is used during insertion of the tracheostomy tube. It is removed
following insertion and replaced with the inner cannula. It’s smooth rounded
end makes insertion less traumatic to the tissues.

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Suctioning Artificial Airways Learning Package 21

http://www.cpem.org/html/aiflist.html

Single Cannula
ƒ Slightly longer than the universal tube
ƒ It is used for patients who have long or thick necks
ƒ This tube usually requires additional humidification to prevent the accumulation
of secretions which could lead to occlusion

www.cpem.org/html/giflist.html

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Suctioning Artificial Airways Learning Package 22

Fenestrated
ƒ These tubes have an opening on the posterior wall of the outer cannula, which
allows air to flow through the upper airway and trachesotomy opening.
ƒ This air movement allows the patient to speak and produce a more effective
cough. The fenestrated tube is often used during weaning to ensure that
patients can tolerate breathing through the natural airway before tube removal.
ƒ It carries the significant risk of tissue overgrowth of the fenestrations and
subsequent tissue trauma upon removal if left in place too long.

Decannulation Plug

ƒ It is attaches to the outer cannula after the inner cannula has been removed
ƒ It blocks air flow through the tracheostomy tube and directs breathing through
the mouth and nose
ƒ To be used only on cuffless tracheostomy tubes or when the cuff is totally
deflated
ƒ Cuffed trachostomy tubes must be totally deflated before decannulation plug
is put on
ƒ Designed to facilitate tracheostomy tube weaning and voice restoration
ƒ It is a universal size – will fit any tracheostomy tube weaning and voice
restoration
ƒ It is a universal size – will fit any tracheostomy tube
ƒ Can be difficult to put on (patient coughing)
ƒ Can be scary the first time for the patient
ƒ May have a lot of secretions at first (due to deflation of cuff)
ƒ Can eat with plug in place – assess swallow first
ƒ Oxygen given via nasal prongs or mask
ƒ When not in use – put in sterile container
ƒ Clean with soap & water, rinse thoroughly

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Suctioning Artificial Airways Learning Package 23

5.0 REVIEW QUESTIONS

NAME: DATE:

1. State three reasons for suctioning an artificial airway.


1)

2)

3)

2. What signs and symptoms indicate a need for tracheotomy or endotracheal tube
suctioning?
1)

2)

3)

4)

3. Answer True (T) or False (F) to the following questions:

1) Tracheostomy/ETT suctioning is painless, causing no ‰ True ‰ False


anxiety to the patient.
2) Routine suctioning should be avoided. ‰ True ‰ False
3) Suctioning is effective only for exudate in the upper ‰ True ‰ False
airways.
4) The patient should be positioned at 30o upright if ‰ True ‰ False
possible during suctioning
5) The suction apparatus may be set at any pressure ‰ True ‰ False
depending on the viscosity of the secretions.
6) Sterile normal saline is routinely instilled prior to each ‰ True ‰ False
suctioning episode to help loosen secretions.

4. List three signs that suctioning has been effective.


1)

2)

3)

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Suctioning Artificial Airways Learning Package 24

5. Complete the following table matching each complication with symptoms and
preventive measures in columns 2 and 3.

COMPLICATION SYMPTOMS PREVENTION


1. Hypoxemia

2. Trauma of respiratory
tract

3. Infection

4. Atelactasis

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